2.0 Analysis 2.1 Frequency of Pitt River Bridge openings Although the Pitt River Highway Bridge spans are not frequently required to open, their correct operation is extremely important to maintain both highway and marine traffic flow. With some 80000 vehicles passing over the bridge every week day, there is considerable pressure on the bridge tenders to keep the highway closure periods down to a minimum. This is reflected in the irate motorists making threats to the bridge tenders. To avoid large traffic build-ups, bridge openings are left to the last possible minute in spite of the fact that some 90 swing span failures were recorded in the two-year period between 1999and2000. 2.2 Testing of Bridge Swings Because of traffic and budgetary constraints, the testing done after the installation of the new equipment was not exhaustive. As a result the testing did not identify all the deficiencies in the system. The hardware and software installed to operate the Programmable Logic Control Units were also not exhaustively tested before the operation of the Pitt River Road bridge (the processes of opening and closing) was computerized. Given these restraints, it was further not possible to optimise the interaction of all the components to deal with the effects of seasonal and climatic change. 2.3 Operating Procedures for Opening and Closing Swing Spans The manual procedure for opening and closing the swing span is straightforward and accomplished by the bridge tender following 'on screen' prompts. There are however, no established comprehensive standard operating procedures to follow in the event of a malfunction. Often, upon encountering a failure of the automatic opening process, the tender switches over to manual and re-tries the last operation in the sequence. While this is frequently successful and the bridge can then be opened, it has the detrimental effect of erasing the record of the previous defect, making it extremely difficult for maintenance staff to later identify the cause of the breakdown. This in turn makes identification of systemic deficiencies difficult and time consuming. 2.4 Visibility from Bridge Tower When problems are encountered with the opening or closing of the spans, or with vessels approaching the span, the bridge tender has to follow the sequence of operations and the prompts as they appear on the two monitors in front of him. Because the operator cannot leave his station in front of the monitors, he is unable to physically view the position of the swing span or to visually assess the unfolding situation vis--vis marine traffic. Since the washroom is located on a different level from the bridge tender's control station, he may be absent from his control station at critical times. After the loading of the barges at the quarry was completed, the master attempted to contact the bridge tender on VHF channel 74. The bridge tender was not at the control station at this time. The layout of the control tower is not conducive to 'one-man operation' during bridge swing span operations. 2.5 Protocol for Marine Traffic during Bridge Transits With the introduction of the Canada Marine Act, the Fraser River Harbour Commission was conferred the status of a Canadian Port Authority. On 01July1999, the Fraser River Harbour Commission became recognized as the Fraser River Port Authority. Under the Port Authority Operations Regulations which are made pursuant to the Canada Marine Act, new Practices and Procedures for the Fraser Port were introduced on 1July2002. The Sailing Directions, British Columbia Coast (South Portion) will be updated accordingly. In the interim, other than the regulations contained in the Fraser River Harbour Commission By-Laws, there is no established protocol to help marine traffic safely transit the bridge spans. The Port Authority, as an agency responsible for the safety of Fraser River waterways (within their jurisdiction) and the bridge operating company, under a contract from the British Columbia Ministry of Transportation to operate the bridge, provide the tools for vessels to safely transit the bridge span. The mariner has to rely on the prompt and efficient opening of the bridge span to safely transit the bridge area. This is consistent with the requirements contained in the Navigable Waters Bridge Regulations that bridge spans be opened immediately, or as soon thereafter as is reasonably possible, to permit the passage of the vessel. Further, regulations emphasize the requirement for efficient, reliable service to the marine community. As the management has no established written procedures for the opening/closing of bridges, the practices used by the bridge tenders of delaying the opening of the bridge has become the accepted norm. This practice effectively diminished/eradicated the significance of the signal lights, breaching the primary defence barrier. 2.6 VHF Communication and Signal Lights During Transit There are no set procedures for communication using VHF radios between the vessels and the bridge tender. This contributes to the risk involved, should it be necessary to slow down a tug's progress to allow a bridge span to fully open, or even abort the transit altogether, in the event of a failure in the bridge system. The tug master is also unable to get a clear indication of the situation from the signal lights mounted on the ends of the protection pier which indicate only if the bridge spans are open or closed to marine traffic. Therefore, the crew of a tug has neither an established means of radio communication with the bridge tender, nor a visual means of determining an intermediate status of the position of the bridge's swing span. Despite this, the tug master continued to approach the bridge and was faced with a reduced number of options to abort the transit. Similar concerns arose in a recent Transportation Safety Board of Canada (TSB) investigation (TSBReportNumberM99W0078) concerning the Fraser River Mission Bridge. 2.7 Bridge Transit Safety Scheduled span opening/closing times for marine traffic are stipulated in the Sailing Directions. The master requested the bridge opening within this stipulated time frame. He informed the bridge tender prior to the vessel's departure from berth some two hours prior to arrival at the bridge and subsequently when the vessel was 10minutes steaming time away from the bridge. The purpose of these calls is to provide sufficient notice to bridge tenders to open the bridge in a safe and efficient manner. Furthermore, it also helps the master to plan the vessel's departures and/or adjust the passage speed(s) so as to ensure a safe and efficient transit with minimum disruption to the road traffic. In the event that the timing is inappropriate for the vessel's transit through the bridge cutting - be it due to an emergency or due to unforseen circumstances - earlier and timely information from the bridge tender to the vessel would permit the master to take appropriate measures - be it delaying the vessel's departure from the berth and/or make an adjustment in speed - for the safety of the tug and tow operations. Such an approach would further the safety of marine traffic, especially during difficult operations such as a tug hauling a tow on a short line under ebb tidal and current conditions where the practice of commencing the opening of the bridge as the vessel approaches a mile off may not always be appropriate. The establishment of Call-in-points (CIPs) and abort points have been used effectively in the marine environment for transits through bridge/lock openings. Such an approach, together with well-established bridge operating practices and procedures, will help ensure that vessel masters, as well as bridge tenders, fully understand their roles and responsibilities and respond in a well coordinated manner. Further, it would help ensure an efficient and safe transit of vessels to the benefit of the safety of road and marine traffic. Prompt notification of bridge operating equipment failure to the vessel is essential for the master to determine risk and initiate additional measures. In emergency situations such as this, the bridge tender may become preoccupied with remedying the situation. This may result in a delay in notifying the vessel. A warning system that automatically displays the status of the bridge operating machinery could help ensure timely notification to the approaching vessel and would be an additional safeguard against human error. 2.8 Bridge Maintenance and Repairs 2.8.1 Computer readouts The Status Read on the bridge tender's computer monitor often gives an incorrect indication and therefore cannot be used as a reliable means of fault-finding and trouble-shooting. Faulty execution of a 'swing' command could be as a result of defective software (programming) or hardware (electrical, mechanical or hydraulic). However, because of operational exigencies, bridge tenders have to resort to every available means at their disposal to complete the 'swing'. They do this by switching over the PLC controlled process from 'auto' to 'manual'. This has the effect of clearing the computer record of the fault which caused the cessation of the automatic process. Maintenance staff is hence, unable to determine the cause of the malfunction, and effective repair is rendered difficult. 2.8.2 Procedures to Identify the Causes of Malfunctions According to Ministry protocol, after a malfunction of the 'swing' operation, an electrician from the Electrical Department is first called in. This electrician inspects the bridge and its machinery to determine if the fault is electrical or if it necessitates the calling out of mechanical or electronics technicians. This protocol leads to delays in rectifying the problem and often results in lengthy periods when the bridge cannot be opened to marine traffic. Because the various departments involved in the repair and maintenance of the highway bridges have not set up a database where faults and the steps taken to rectify them are documented, there is no record of the causes of these failures. The establishment of a suitable database would allow pooling of inter-departmental information, essential for the timely identification and repair of defects. Although the bridges have a history of malfunctions (especially post computerisation), there has been no effort on the part of the relevant departmental heads to meet regularly to discuss these problems. Reportedly, many problems are software related, are of a recurrent nature and date back to the initial installation and programming of the PLCs. However, effort has not been made in a timely manner to contact the designer of the software to attempt to identify and remove these problems. 2.9 Marine Traffic 2.9.1 The Transit After loading at the quarry, the master of the MillerRichmond requested clearance to transit the Pitt River bridges, two hours in advance of his ETA. Later, about one mile upstream of the bridges, he reconfirmed this ETA. The bridge tender however delayed the opening of the spans until the last minute to minimise the disruption to highway traffic. When the bridge failed to open, the tug and its tow were too close and the master had to take immediate and drastic action to avoid hitting the bridge. He turned hard to port knowing that the width of the river did not offer him enough room to execute a 180 turn and that he would almost certainly run aground. This influenced his decision to abort the turn and re-attempt the transit when, a few minutes later, the bridge tender called him back to inform him that the span was now opening. In the short distance remaining, he was unable to realign his tow which was instrumental in causing the second barge to strike the protection pier. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The south span of the Pitt River Highway Bridge failed to open as the MillerRichmond and her tow were making their final approach to the draw. To minimise the disruption to highway traffic, the bridge tender had delayed the opening of the spans. Consequently, when the swing span failed to open there was an insufficient margin of safety for the tug to take early avoiding action. Attempting to avoid or minimize damage to the unopened span, the master of the MillerRichmond started to abort the transit. Shortly afterwards, when the bridge tender succeeded in opening the bridge span, the master of the tug could not sufficiently re-align the tow to navigate safely through the draw and the barge Miller201 collided with the protection pier. The master continued to approach the bridge and pass limits where alternative action could be taken despite a lack of visual indication that the bridge was opening. 3.2 Findings as to Risk The number of bridge span opening failures (some 90were recorded in the two-year period between1999 and2000) has increased since the computerisation of the Pitt River Road Bridge. Although the bridges have a history of malfunctions (especially post computerisation), there has been no effort on the part of the relevant departmental heads to meet regularly to discuss these problems. The hardware and software installed to operate the Programmable Logic Control Units were not exhaustively tested before the operation of the Pitt River Road Bridge was computerized. The several entities involved in the operation, repair and maintenance of the highway bridges do not have a common database where the information on the causes of the frequent malfunctions since computerization can be recorded or stored - or where the corrective measures taken can be documented. There are no established Calling In/Abort Points in the vicinity of the Pitt River swing bridges to indicate the proximity of vessels to bridge tenders and where vessels may safely abort transits in the event of a failure of the swing bridge mechanism. In the event that a bridge span fails to open, bridge tenders switch from the PLC-controlled process (auto) to manual control which clears the computer-stored record of the cause of the malfunction. Maintenance staff is thus unable to access the computer-stored diagnostic of the cause of the malfunction and repairs are delayed until a comprehensive inspection is made. 3.3 Other Findings Other than the regulations contained in the Fraser River Harbour Commission By-Laws, there is no specific protocol established to help marine traffic safely transit the bridge spans. The system of bridge opening lights indicates to shipping that the span(s) are either open or shut. The lights do not indicate an intermediate status of the process to vessels using the Pitt River bridges. The nominal range (intensity) of lights installed on bridges for the purpose of marine navigation is not consistent within the same geographic area. The layout of the bridge tender's control tower is not ergonomic and is not conducive to 'one-man operation' when operating the swing bridge. 4.0 Safety Action 4.1 Action Taken Since the operation of the bridge spans was computerized, the more commonly occurring faults with limit switches, sensors and relays have been addressed. Following the accident, a gate secured by wire ties is in place to prevent public from gaining easy access to the bridge tenders. 'Practices and Procedures for the Fraser River Port Authority', which replaced the 'Fraser River Harbour Commission By-Laws' were published and came into effect on 1July2002. In March, 2002 the TSB issued two Marine Safety Information (MSI) letters dealing with shortcomings identified during the investigation. MSI02/2002, issued 6March2002 was addressed to the Navigable Waters Protection Division (NWPD) of the Canadian Coast Guard. The MSI letter dealt with inconsistencies in the application of standards for Marine Navigation Signal Lights on Bridges and Structures. The NWPD was requested to review their procedures regarding lighting development at bridges in order to mitigate risks to bridge and vessel users. The TSB has yet to receive a response to this communication. However, a response to a copy of the letter, sent to the British Columbia Council of Marine Carriers, indicates the Council's willingness to work with all parties concerned to encourage a consistent application of the process to achieve consensus on such matters. MSI 04/2002, issued 28February2002, was addressed to the British Columbia Ministry of Transportation, District Highways Branch. This letter dealt with the implementation of standard operating procedures for bridge openings and communications, an effective maintenance system to rectify frequent swing span failures, and the ergonomics of the control tower. The Ministry of Transportation discussed the issues raised in the MSI but the TSB is not aware of any action taken to address them. 4.2 Action Required 4.2.1 Coordination and Procedures for Bridge Transits by Vessels Procedures necessary to ensure safe operations concerning bridge transits by vessels involve the close coordination of the Fraser River Port Authority, the provincial Ministry of Transportation, bridge tenders and vessel operators. Since this occurrence, there has been no information received by the Board to indicate that the parties have met with one another to conduct an overall review of operations and procedures for bridge transits by vessels. Also, there has been no indication of a coordinated review by the parties concerning the dissemination of transit procedures to the marine community. Any successful bridge transit by a vessel also involves close interaction between the bridge tender and vessel operator. This requires clear and established communication, approach and transit procedures that take into account both routine and non-routine situations, such as the failure of the span to open. Regulations about operations and signal lights concerning the Pitt River Railway Bridge and the Pitt River Highway Bridge were stipulated in sections59 and60, respectively, of the Fraser River Harbour Commission By-Laws and published in Sailing Directions, British Columbia Coast (SouthPortion)5. Furthermore, a vessel that had signalled for the swing span of the Pitt River Highway Bridge to be opened was required to remain at a safe distance from the bridge until the green signal light at the end of the swing span was given to indicate that the span was open. However, the practice of delaying the opening of the bridge, which evolved over the years, effectively diminished/eradicated the significance of the green signal light breaching the primary defence barrier. Further, the By-Laws were repealed upon the coming into force of the Port Authorities Operations Regulations on 1March2000. The Port Authorities Operations Regulations do not deal with bridge transits by vessels. Information concerning the transiting of the Pitt River Railway Bridge and other railway bridges by vessels within the jurisdiction of the Fraser River Port Authority is now contained in the Authority's Practices and Procedures, established pursuant to section56 of the Canada Marine Act. The purpose of the document is to promote the safe and efficient navigation in the waters of Fraser Port. The document, however, does not contain information about signal lights for the various railway bridges nor does it contain any information about the Pitt River Highway Bridge that was in the previous regulations. Given that the above-mentioned safeguards are no longer in place, and that there is lack of coordination among parties responsible for ensuring efficient and safe operation of bridges, vessels, bridge structures and bridge users may continue to be placed at undue risk during vessel transits. The Board, therefore, recommends that: The Fraser River Port Authority and the provincial Ministry of Transportation, in collaboration with the bridge tenders and vessel operators, review and, if necessary amend, their current policies, practices and procedures, and ensure implementation so that the safety of vessels, bridges and bridge traffic is not compromised.